Chapter 8 - Intrapartum Assessment + Interventions Flashcards
Premonitory Signs of Labor
- backache
- rupture of membrane
- wt loss (1-3.5 lb)
- lightening
- regular contractions
- incr discharge/bloody show
- energy burst
lightening
As the fetus’s head settles deep into your pelvis, you may feel that the fetus has dropped lower
- you can breath again!
- but now u may be peeing more
ways to confirm ROM
- speculum exam
- ferning
- amnisure testing (detects PAMG-1, an amniotic fluid)
- nitrazine paper (turns blue w amniotic fluid)
nursing actions if ROM is suspected
- assess FHR
- assess amniotic fluid for color, amt, odor
- document date + time SROM + assessments
amniotic fluid characteristics
clear or cloudy w normal odor like ocean water
-if meconium stained, then contact HCP bc it may indicate fetal compromise in utero
Mechanisms of Labor are the…
positional changes in the presenting part required to navigate the birth canal
-aka cardinal mvmt
Mechanisms of Labor is composed of…
- engagement
- descent
- flexion
- internal rotation
- extension
- external rotation/Restitution
- expulsion
engagement
when the greatest diameter of the head passes thru the PELVIC INLET
-late pregnancy, early labor
descent
mvmt of bb thru birth canal during 1st + 2nd stages of labor
flexion
when chin of bb moves towards chest
- happens when head meets resistance fr tissue
- early in labor
internal rotation
when long axis of the head lies along axis of the pelvis
-2nd stage of labor
extension
head pivots underneath the pubic symphysis
- caused by resistance of pelvic floor
- during 2nd stage, when head is delivered
external rotation/Restitution
head + shoulders rotate to move under symphysis pubis
expulsion
anterior shoulder comes first followed by the rest of the body
6 best practices that promote normal physiological birth
1 labor starts on its own 2 freedom of mvmt 3 continuous support 4 minimize interventions 5 spontaneous pushing in non-supine 6 no separation bw bb + mom
4 stages of Labor
1 start: onset of labor, end: complete dilation
2 start: complete dilation, end: bb delivery
3 start: after deliver of bb, end: delivery of placenta
4 start: after delivery of placenta, end: 4 hrs later. aka postpartum period
characteristics of 1st stage of labor
- longest stage
- bag of waters or fetal membrane usually ruptures
- incr in CO + pulse
- decr in GI motility
- pain assoc w UC
- 3 phases
nursing actions of 1st stage of labor
- limit oral intake to clear liquids
- woman dictates carb intake to decr ketosis
- frequent position changes + upright
- frequent emptying of bowel/bladder
- comfort measures
- emo + phys support
phases in first stage of labor
latent: <5cm
active: >6cm
transition: 8-10 cm
nonpharm actions
- emo stupport
- comfort measures (ice chips, fluids, food)
- hygiene (pericare, mouth careO
- position changes
- touch/massage
- calm environment
- advocacy
- reinforce relaxation/breathing
latent phase of stage 1
- dilatn 0-4cm
- effacement 0-40%
- mild contractions Q 5-10 min (like strong menstrual cramps)
nursing actions in latent phase
- start IV or insert saline lock
- double check Rh, GBS, urine for protein/gluc
- assess (VS, FHR, UC, membrane status, amniotic fluid, edema, hrt lung sounds,
- sterile vaginal exam: dilatn + effcmt, presentation, position, station
- leopold maneuver
leopold maneuver
assess position of bb
- determines what part of fetus is in fundus
- location of fetal back
- presenting part
- location of cephalic prominence
if GBS is pos…
give IV of penicillin
-ampicillin is alt
sterile vaginal exam directions
- labia is separated w sterile glove hand
- fingers are lubed
- locate cervix
sterile vaginal exam assesses….
- dilation
- effacement
- position
- station
- presentation
- fetal position
dilation in SVE
sweep finger fr side to side on margin of cervical opening
effacement in SVE
estimates shortening of cervix fr 2cm to paper-thin
position in SVE
relationship of cervix to head
-posterior, midposition, or inferior
station Iin SVE
level of presenting part in birth canal
- 0 when presenting part reaches ISCHIAL SPINE
- (-) still inside, (+) when outside
presentation in SVE
cephalic, breech, shoulder
ferguson’s reflex
urge/readiness to bear down
- phys response of women
- activated when presenting part is at least 1+ station
when is intrapartum GBS prophylaxis indicated?
- previous bb w invasive GBS disease
- GBS bacteria during current pregnancy
- pos GBS vaginal-rectal culture in late gestation
- unknown GBS status at onset of labor w <37 nwks
- ROM> 18hrs
- temp >100.4
s/s of active phase of 1st stage of labor
- > 6cm
- decr energy, fatigue
- contractions more intense, Q 2-5min, lasts 45-60 sec
nursing actions for active phase of 1st stage of labor
- FHR + contractions Q 15-30 min
- VS Q2 hr
- –Q1 hr if rom
transition phase of 1st stage of labor
- complete dilation
- easily discouraged, irritable
- intense contractions Q 1-2 min, lasts 60-90 sec
- incr bloody show
- backache
- strong urge to bear down or push
if pt has backache…
hand goes over hip, rubbing + pressing on area
nursing actions for transition phase of 1st stage of labor
- FHR + UC Q 15 min
- breathe during contractions + rest bw contractions
2nd stage of labor phases
latent/resting: urge to bear down is usually absent, fetus is passively descensding
descent/active phase: incr intensity of UC + strong activation of ferguson’s reflex
bearing down in the __ stage is less tiring + more effective + when started after the ___ rather than before
2nd stage> ferguson reflex (stron gurge to bear down)
2nd stage of labor characteristics
intense UC Q2min lasting60-90 sec
- bloody show incr
- perineum flattens
pushing education
- push for 6-8 seconds, followed by slight exhale
- repeat for 3-4 pushes per contraction
- discourage traditional practice of breath holding for 10 secs w each contraction
perineal stretching care for 2nd stage of labor
- warm compress
- gentle massage w warm oil
Episiotomy
incision in perineum to provide more space
Types of Episiotomy
1 median/midline
2 medilateral
median/midline episiotomy
heals more quickly w less discomfort
medilateral episiotomy
45 degree angle incision
- heals more slowly
- greater blood loss
- more painful
Lacerations
tears in the perineum
-can occur in cervix, vagina, perineum
1st degree Lacerations
perineal skin + vaginal mucous membrane
2nd degree Lacerations
skin, mucous membrane, FASCIA of perineal
3rd degree Lacerations
skin, mucous membrane, MUSCLE of perineal, EXTENDS TO SPHINCTER
4th degree Lacerations
extends to RECTAL MUCOSA + exposes LUMEN of rectum
3rd Stage of Labor
separation + expulsionof placenta
- sudden decr in uterus size
- UC continues until placenta is expelled
Active Management of Third stage of Labor + goals
- uterotonic drug (OXYTOCIN)
- controlled cord traction
- fundal massage
goal is to decr PPH + incr UC + placenta expulsion
normal blood loss
500 mL w/in 24 hr
3rd stage of labor nursing actions
- at delivery, bb is placed on mom for skin-to-skin
- if 3rd stage lasts more than 30 min, IV/IM of oxytocin 10IU
- if placenta is still retained, then manual removal
- if manual removal is being performed, then prophylactic abx is admin
primary mechanism to return to hemostasis
vasoconstrictions fr well contracted myometrium
when is apgar score obtained?
1 min, 5 min
-if apgar score is less than 7, then Q5min for 20 min
3 meds routinely administered to newborn
1 erythromycin
2 vitamin K
3 hepatitis B
erythromycin
ointment admin to eyes as prophylaxis ointment
-prevents gonococcal + chlamydia infections
vitamin K
via IM injection
-prevents hemorrhagic disease caused by vit K deficiency
Hep B vaccine
recommended for all newborns
initial assessment of newborn
airway, breathing, circulation, drug
